Michael McMonigle

1. 1. lack of knowledge of leave policy

   “The lack of knowledge of the policy for leave for informal patients amongst ward staff and the Consultant [name redacted] in particular.”

2. 2. failure to conduct assessment before handover

   “The failure to follow the policy in terms of conducting an assessment prior to the handover.”

3. 3. failure to communicate leave arrangements

   “The failure to apply the policy in terms of ensuring that leave arrangements are clearly understood by the patient and communicated to relatives.”

4. 4. risk assessment not updated after formulation meeting

   “The Face risk assessment, PARIS case notes and intervention plan were not updated with assessment of risk of self-harm and suicide and details of conditions for escorted leave following the formulation meeting on 10”

5. 5. delayed response to patient absence

   “Failure to respond to [the deceased]'s absence until well after 19:20 hrs, when it was admitted by ward staff in evidence that interventions could have been commenced, alternatively 21:00hrs when it was conceded that the alarm could have been raised given that that was the normal time for return from leave.”

6. 6. non-compliance with Missing Patients Procedure

   “The response to [the deceased]'s absence did not conform with paragraphs 7.3 of the Missing Patients Procedure, ref. CLIN-0006-V4 in that there was no search of the hospital internally, a search of the grounds, enquiry with other staff users, check of CCTV footage.”

Linked reports

No published response was found on judiciary.uk.